All healthcare organisations have a requirement and a patient obligation to manage patient records in the most efficient and secure manner.
Simple and availability to secure patient records creates efficiency in performing administrative tasks that are essential to record-keeping. Invoicing and forms processing should also be streamlined to minimise manual work, human error and to protect privacy.
This post explores these obligations in more detail, illustrating the best practices in patient record management for a healthcare business.
Why are secure patient records so important?
A patient record holds confidential and sensitive information and so it is imperative that patient records remain secure.
High-quality records are complete, accurate and legible records, and when stored and secured correctly, can be efficiently shared between practitioners and other health services with the patient’s permission. In this way, secure patient records facilitate:
- Competent decision making
- Effective communication
- Trust between practitioner and patient, and
- Continuity of care
How can secure patient records be sustained?
Systems and management
The quality of your patient records is dependent on the quality and suitability of the health record system within your organisation. A health record system specifies the way patient information is collected, recorded and stored. A system such as this will include whatever policies and procedures a healthcare organisation will follow, staff training and education on the system, initial implementation and then its ongoing management. Some health organisations will give ownership of the entire system to a specific staff member, who takes on the patient record strategy and management responsibilities.
Policies, procedures and protocols
There are a number of important policies, procedures and protocols required to ensure quality records, covering:
- Retention requirements
- Disposal requirements
- Digital and manual file storage and transport systems
- How clinical information is recorded
- Access to records at the point of care
- Emergency access to records when a patient is unable to consent
- What information is recorded to effectively monitor the quality of care
- Availability of formal reports, for example, imaging and pathology tests
- How changes to the record are authorised
- How and when compliance audits are undertaken
- Compliance with the relevant standards and professional and legislative requirements.
All policies, procedures and protocols should be detailed, documented and evaluated periodically to ensure the record system is as effective and efficient as possible. Organisations should also examine employee compliance with policies and consider regular training and education to support this.
Training and education
While training may start with the implementation of a new record system, or as a new employee is onboarded, this is not where it ends. To ensure high-quality, secure records staff training and education is an ongoing and continual requirement. All staff, clinical and administrative, should be included in regular training which always enforces the importance of record security and maintenance and how the organisation's system supports this.
Staff education may include sessions on:
- Identifying the information required for a patient record
- Records management standards (eg. retention, confidentiality, disposal and more)
- The risks of incorrect information being recorded
- Software features if electronic records are stored digitally
Consider knowledge gaps that exist in your organisation so you are able to address the specific training needs of your employees. If you're not sure what gaps persist, ask your staff for their input.
Security and compliance
Given that information about a person's physical or mental health and wellbeing is both private and sensitive, it is of utmost importance that patient records are securely kept. When it comes to security and compliance, it is the responsibility of the organisation to comply with relevant jurisdictional legislation.
With the increasing uptake of electronic records management, there is also an increase in concerns regarding how secure information is when used across computers and mobile devices like smartphones or tablets. Naturally, the secure exchange of information, whether manual or digital, between practitioners is another pressing concern for many. To ensure both high-quality patient records, compliance and patient trust, health organisations must implement effective security measures to protect the confidentiality of patient data.
With the right technology, health organisations have an opportunity to improve the accuracy and security of their patient records. Not only this, but the right software solution can also make processes faster and easier.
Electronic Content Management (ECM) or Electronic Health Record software (EHR) automates the documentation, storage and retrieval of high-quality patient records. EHR software facilitates efficient data entry, minimises the need for manual paper records, produces up-to-date patient histories, automates diagnosis and code selection, decreases or completely eliminates transcription costs and decreases time spent retrieving patient information.
A suitable ECM solution will enable your staff to quickly and easily access records while supporting your organisation to provide relevant, accurate, up-to-date and complete patient information. Some of the other benefits of ECM software include:
- Securely sharing digital information with patients and other healthcare organisations
- Enhancing communication with patients
- Empowering safer and more reliable diagnosing and prescribing
- Promoting legible, complete and accurate documentation
- Enabling the privacy and security of patient data
A new ECM will change how people work and affect the way documents are managed right across your organisation. It's not an easy or quick decision to make, but our Enterprise Content Management Checklist will help you consider your options and identify the right ECM to meet your business needs.